Our patient safety approach reflects a commitment to creating a safe environment, proactive learning, transparent communication, and collaboration across different teams and groups. By placing patient safety at the forefront of everything that we do and integrating it into the organisation’s culture, WMAS aims to provide the best possible care while minimising risks and adverse incidents. We take a comprehensive and proactive approach to patient safety which is centred around preventing errors, minimising harm, and continually improving patient care.
Patient Safety Incident Response Policy (179kB pdf)
Patient Safety Incident Response Plan (184kB pdf)
Here are some key components of our patient safety approach:
Priority on Patient Safety: We consider patient safety a fundamental aspect of delivering high-quality care. The goal is to create a safe environment where patients are protected from avoidable harm.
Error Prevention: The Trust emphasises the prevention of errors and the adverse effects associated with healthcare delivery. This involves implementing measures to identify and minimise risks to patient safety.
High-Quality Care: We are committed to delivering high-quality, safe, and effective patient care. This commitment extends to both patients and employees, aiming to control risks to all individuals involved.
Reporting and Learning: The Trust emphasises the importance of reporting systems for adverse incidents and near misses. This reporting enables a structured approach to reviewing incidents and learning from them, which in turn leads to improvements in patient care and staff safety.
Duty to Report: There’s a clear directive for staff, the Patient Safety Team, and others to report and record any incidents or potential risk. This proactive reporting helps identify areas for improvement and risk mitigation.
Patient Safety Team: The Team plays a crucial role in reviewing, learning from, and improving care from incidents. Their responsibility extends to identifying and managing harm incidents as well as ensuring that recommendations are acted upon for ongoing improvement.
Transparency and Communication: The approach emphasises a culture of openness, where communication is honest, transparent, and occurs promptly following incidents. This approach includes apologising and explaining what happened to patients who have experienced harm due to the treatment we have provided.
Partnership and Collaboration: WMAS collaborates with a variety of other organisations and groups such as the Serious Incident Review Group (SIRG), Learning Review Group (LRG), and Integrated Care Boards (ICBs). This partnership approach ensures that learning is shared, discussed, and applied across the organisation.
Patient Safety Incident Response Framework (PSIRF): The introduction of PSIRF demonstrates a commitment to staying aligned with national patient safety initiatives and continuously improving the way we respond to patient safety incidents in the future, in line with four key aims:
- To allow a more proportionate response to safety incidents.
- To allow a greater range of responses to incidents, as opposed the reliance of formal investigations.
- To improve support to, and the involvement of, affected patients, staff, and families.
- To improve existing governance and oversight procedures.
Clinical Strategy Monitoring: This ensures that we deliver the highest quality of patient care by conforming to the correct standards by carrying out checks for compliance and adhere to the core principles as set by the Trusts vision and values of Excellence, Integrity, Compassion, Inclusivity and Accountability.
Continuous Improvement: The Trust’s focus on continuous improvement is evident through its commitment to learning from incidents, implementing recommendations, and evolving its practices based on lessons learned.
What is Patient Safety?
According to the National Patient Safety Agency, a patient safety incident is defined as:
Any unintended or unexpected incident which could have or did lead to harm for one or more patients receiving NHS care.
Duty of Candour/Being Open
Promoting a culture of openness is a prerequisite to improving patient safety and the quality of healthcare systems. It involves apologising and explaining what happened to patients who have been harmed as a result of their healthcare treatment. It ensures communication is open, honest and occurs as soon as possible following an incident. It encompasses communication between healthcare organisations, healthcare teams and patients and/or their carers.
Duty of Candour must be enacted where actual harm has occurred to a patient that has been measured as moderate, severe or death.
- Moderate harm – non-permanent serious injury or prolonged psychological harm e.g. wounds requiring further care, fractures
- Severe harm – where permanent serious injury has occurred as a result of care provided e.g. injuries requiring surgery, life changing injuries
- Death – the death of a patient when due to treatment received or not received e.g. a patient with a known allergy to penicillin administered said drug who then has a anaphylactic reaction and a fatal cardiac arrest
There may be occasions where it is appropriate to embrace openness beyond the statutory duty of candour definitions, for example, where there is a significant near-miss however, this is not a statutory obligation and is covered by being open.
Learning Review Group (LRG)
The purpose of the Learning Review Group is to ensure the Trust recognises the benefits of learning from its untoward events including all those identified through complaints, concerns or the incident reporting system.
The objectives of the group are:
- To provide assurance that the Trust is investigating, reviewing and learning from high risk adverse events arising from clinical and non-clinical incidents, complaints, PALS, clinical audit, national benchmarking, coroners inquiries and legal claims to ensure continuous improvement in quality of service
- To identify concerning incident trends arising from analysis of all data collated through incident reporting, complaints, claims, Board visits, etc. both where harm/damage has occurred and near misses
- To provide recommendations to reduce both the likelihood and consequences of further similar incidents occurring
- To ensure learning is shared across all areas of the Trust and with local and national stakeholders and partners
- To review national ambulance benchmarking and identification of learning points for West Midlands Ambulance Service
- Analysis to include identification of risks for review or addition to the Trust Risk Register.
The group will be chaired by the Director of Nursing with a membership that includes representatives from:
- Patient Experience
- Claims
- Clinical audit
- Clinical
- Frontline A&E operations
- Risk
- Patient Transport Service
- Education and Training
- Emergency Operations Centres
- Staffside
There is also an open invite to Non-Executives and Commissioners.
Engaging With Those Involved in Patient Safety Learning Responses
We are committed to delivering safe, high-quality care. However, we recognise that healthcare is complex, and situations can change unexpectedly.
Occasionally, despite our best intentions, things do not go to plan, and a patient safety incident can occur. A patient safety incident is any unintended, or unexpected incident which has or could lead to harm for one or more patients receiving healthcare. These can range from incidents causing “low harm” such as a bruise or skin tear, to more significant incidents which can have a devastating impact on someone’s life.
A legal Duty of Candour reinforces our principles of being open, alongside involving our patients and their families in the review of patient safety incidents. The statutory duty states that healthcare providers ensure that patients are told openly, honest and in a timely manner when mistakes happen which are believed to have caused significant harm. If a patient lacks capacity to make decisions in relation to their care, or has died, we will involve their families in these discussions.
We are committed to talking to our patients, families and carers at the earliest opportunity to allow us all the understand what has happened, and where necessary, learn to prevent harm reoccurring and improving safety for our patients.
If the care is being reviewed as a Patient Safety Learning Response under the Patient Safety Incident Response Framework (PSIRF), one of our Learning Leads will contact the patient or their family to apologise and discuss the circumstances of the incident.
We will offer support for patients and families to participate in in the Learning Response and will appoint a Learning Response Lead as a single point of contact.
We will:
- Ask how much patients, families/carers wish to be involved in the review process
- Talk to those involved, including our staff to gain an understanding of the incident
- Patients and families/carers will be able to ask questions and share their experiences
- Review all information in relation to the incident such as medical notes
- Consider all of the human factors that may have led to the incident
- Share our findings with patients, families/carers
- Share any learning, and make improvements to our systems and processes to keep our future patients safe